Mealtime Assessment Referral Form

Please complete this document when referring for a mealtime asessment.

A mealtime assessment is the initial process within mealtime services at Autism SA and is carried out by a speech pathologist and an occupational therapist with experience in mealtimes. The mealtime assessment allows for comrehensive multi-disciplinary assessment of the individual's swallowing and safety within mealtimes, sensory and motor impacts that may be impacting on food and drink preferences and independence skills, for example, meal preparation, seating and self-feeding skills. Following completion of the assessment, the therapists will be able to provide clinical recommendations for the mealtime supports and strategies that will be most supportive for that individual.

Costing associated for a mealtime assessment it is $1,551.92.This is a total of 8 hours which includes an in-person assessment and observations, written report and recommendations, and additional individualised required services to support with targeting identified mealtime goals.

Completion of this referral form allows for allocation of the most appropriate mealtime service for the individual based on their identified needs and past mealtime assessment and/or support.

MEALTIME REFERRAL DETAILS

What is the reason for referral (please describe)? *

Has the person received any Mealtime services previously? *

NoYes

If yes, please describe:

Does the client have a current or previous Oral Eating and Drinking Care Plan (OEDCP) or Mealtime Support Plan (MSP)? *

NoYes

If yes, please provide a copy: *

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Please upload any other relevant documents below (e.g. assessments or reports) if available:

Attachment 1

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Attachment 2

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Does the individual experience ongoing coughing, choking, gagging or vomiting when eating or drinking? *

YesNo

Which of the occur for the individual during or after mealtimes? Please select all that apply. *

How frequently does coughing, gagging or vomiting occur?

DailyWeeklyMonthlyOther

How frequently does choking occur?

DailyWeeklyMonthlyLess Frequently than Monthly

Does the individual currently tube fed or history of being tube fed (nasogastric tube or gastrostomy)? *

Yes - currently tube fedYes - previously tube fedNo - never been tube fed

Other/further information

Based on the information you have provided above, Autism SA is unable to provide the appropriate support at this time. We encourage you to seek guidance from your primary health care provider (e.g. your GP) for an appropriate referral.

If you have any questions or concerns regarding mealtime support, please contact the Client Relationships Team on 8379 6976 or via contactus@autismsa.org.au.

CLIENT DETAILS

Client name *

Preferred name (if different)

Client date of birth *

Pronoun

he/himshe/herthey/themother

Diagnosis (please put 'none' if there is no diagnosis) *

Medical conditions/allergies (if any)

What is the individuals approximate height (in cm)? *

What is the individuals approximate weight (in kg)? *

Will you be using NDIS funding or paying Fee for Service (out of pocket)? *

NDISFee for service (out of pocket)

Please upload your NDIS Plan here *

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NDIS number: *

NDIS Plan start date *

NDIS Plan end date *

Plan Nominee (responsible person for making decisions about NDIS services on the behalf of the individual)

My Improved Daily Living *

Self-ManagedPlan-ManagedAgency-Managed

Plan Manager Name *

Plan Manager email address *

Is this a PACE Plan?

YesNo Unsure

Does the client/care team require an interpreter? *

YesNo

If yes, which language?

Other/further information

How does the individual currently communicate? *

Spoken language (phrases and sentences) Spoken language but with limited ability to use language functionally to get needs metNon-speakingUses gestures/ body language to communicate Uses visuals or other AAC

Please detail which AAC system is used:

Other/further information

REFERRAL INFORMATION

Name of individual completing referral form *

Relationship to client (e.g. self, parent/caregiver, support coordinator, etc.) *

Email *

Phone Number *

BEHAVIOUR SUPPORT

Does the individual have a current Positive Behavior Support Plan? *

Yes No

If yes, please upload Positive Behaviour Support plan

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Please specify:

CURRENT MEALTIME SUPPORT NEEDS

Other/further information

Which items does the individual currently drink from? Please select all that apply. *

Other/further information

Which best describes the individual’s current method of feeding? Please select all that apply. *

Fed by othersSelf feeds using hands and/or cutlery

If self feeds, please select which utensils the individual currently uses:

HandsSpoonForkKnife

Other/further information

MEALTIME SERVICE BOOKING PREFERENCES

At time of completing this form my preferences are (tick all that apply):

Specify home suburb

School name

Kindy name

Day Options name/location

If other, please detail:

Time preferences (please select all that apply) *

Any time Specific time/s

Specify time/s

Any other information you would like to provide?

Thank you for completeing the referral form. Please review your answers and click submit.